Insurance Terminologies
Advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
What is an Authorization?
Joint federal and state program that helps cover medical costs for some people with limited income and resources.
What is Medicaid?
The amount of time to submit a claim for payment as designated by the insurance company
What is timely filing?
Services designed to review blood or tissue sample for general health or medical illness.
What is Laboratory?
What is ICD-10?
Federal law that protects the privacy and security of patient’s health information.
What is HIPAA?
Amount you have to pay toward the cost of your healthcare bills before your insurance company begins to cover your costs.
What is a deductible?
Federal health insurance for people 65 or older and some people under 65 with certain disabilities or conditions.
What is Medicare?
A claim that's submitted without any omissions or mistakes. This allows the claim to be processed and paid promptly.
What is a Clean Claim?
Visits that help detect or prevent serious disease before they become major health issues.
What is Preventive Care?
5 DIGIT Procedure Code that starts with an Alpha character
Federal law that requires hospitals to provide emergency medical care to all patients, regardless of their ability to pay.
What is EMTALA?
Providers who have a contract with your insurance company.
What is an in-network provider?
Health plan that contracts with both Medicare and Medicaid to provide benefits of both programs to members.
What are Duals?
Complete list of fees used by Medicaid and Medicare to pay doctors and other medical providers. Generally associated with CPT/HCPCS.
What is a fee schedule?
Admission to a hospital for more than one day
What is inpatient?
4 DIGIT code by facilities when billing
What is Revenue Code?
Federal law that prohibits the exchange of anything of value for referrals or services that are paid for by Medicare or Medicaid.
What is AKS- Anti-Kickback Statute?
Person who is the primary insured person or the one who takes out the insurance.
Who is the primary or subscriber?
The Health Insurance via an exchange that helps you find health coverage that fits your needs and budget.
What is Marketplace?
A fixed payment paid per person enrolled over a period of time, paid to the health plan or provider.
What is Capitation?
Medical supplies that can withstand repeated use and are not beneficial except to the person that needs the equipment.
This indicates where the patient received serivces
What is POS?
Federal law that prohibits physicians from referring patients to certain designated health services (DHS) paid for by Medicare to another entity with which they have a financial relationship.
What is the Stark Law?
A set dollar amount paid with each visit.
What is Co-pay?
An insurance plan that requires patients to see doctors and hospitals contracted with the managed care insurance company. Medical emergencies or urgent care are the exceptions when out of the service area.
What is an MCP or MCO?
Statement that explains payment details, covered charges, contractual adjustments, deductibles, copays, coinsurance, and patient responsibility for multiple members.
What is an EOP?
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living.
What is long term care?
Procedural code set developed by the American Medical Association
What is CPT?
Act passed in 2009 to promote the adoption and meaningful use of health information technology (IT). It provides financial incentives to healthcare providers and organizations that implement and use certified electronic health records
What is HITECH?
Health Information Technology for Economic and Clinical Health